WWW.HSJ.GR – HEALTH SCIENCE JOURNAL ® VOLUME 4, ISSUE 1 (2010) The preference of a Female Greek island population in regard to the gender of their gynecologist Maria Noula 1 , Athina Leontzini, 2 Anastasis Anastasiadis 3 ,Eleni Ifanti 4 1. RN, Associate Professor, Nursing Department of TEI, Lamia 2. RN , Nursing Department of TEI, Lamia 3. Resident Doctor, Obstetrics-Gynecology Department, General Hospital of Tripoli 4. Health Visitor, ΜSc, Laboratory Cooperator of Nursing Department of T.E.I., Lamia Abstract Background. Doctor’s gender is thought to play some role when women select their gynecologist. Purpose. The purpose of this research was to investigate the preference of Greek women in regard to the sex of their gynecologist as well as the factors associated with that preference. Material and method. The population of the study consisted of two hundred women from the broader area of the island of Chios. A self completed questionnaire which included demographic data, the usage of gynecological health care services as well as the choice of the obstetrician – gynecologist was used . Descriptive statistics , x 2 and t-test, and a logistic regression model were applied. SPSS 13.0 v was used. Results. The average age of the 200 women of the sample was 43 ± 11.02 years. 45 % of the participants didn’t report any sex preference, whereas 25% of them reported that they preferred a man and 30% a woman gynecologist. Single women preferred a male gynecologist with statistically significant difference. The women conducting an annual Pap smear check preferred a man in their majority (28 out of 45 women), whereas the ratio changed in favor of the female gynecologist, when the test was conducted less regularly. When the logistic regression model was applied, the strongest correlations were as follows: Women who had visited a gynecologist before they reached 20 years of age were 1.2 times more likely to choose a woman gynecologist (Confidence Interval, CI 1.02 – 1.41) in comparison to the women who were 2 years older. Those who underwent a physical breast examination at rare occasions were 1.7 times more likely to choose a woman gynecologist (CI 1.1 – 2.63) in comparison with the rest of the sample. Conclusions. The women obstetricians – gynecologists are ahead in the women’s preferences, whereas half of the women think that the sex factor is rather insignificant. The older age at the first visit and the sparse physical breast examination are positively correlated with choosing a woman gynecologist. Keywords: Obstetrics and Gynecology, sex, woman’s health Corresponding author: Noula Maria, Pellis 3 145 61, Kifisia Athens Tel./Fax 210 8087573 Mobile :6932 461903, e-mail: mnoula@teilam.gr The preference of a Female Greek island population in regard to the gender of their gynecologist 57 pp:57-65 E-ISSN:1791-809X www.hsj.gr Health Science Journal® All Rights Reserved WWW.HSJ.GR – HEALTH SCIENCE JOURNAL ® VOLUME 4, ISSUE 1 (2010) Introduction he relationship between the gynecologist and the female patient tends to be a long term one. This doctor-patient session constitutes a kind of social relationship during which the sex of the two parties often plays an important role, especially if the doctor examines the patient’s genitals. 1,2,3 Even though a number of studies have dealt with the issue of the factors that influence the choice of the gynecologist, there is no consensus on the role the sex of the doctor plays in the choice the patient makes. Besides, many researchers have found that, no matter the sex choice, the patients, regardless of their age, assess more important characteristics such as the doctor’s behavior and his/her scientific background. 4,5 Since 1974, when an article by Neubardt, "Women's Liberation and the Male Gynaecologist," discussed women's dissatisfaction with the medical profession and the need for female gynaecologists, many studies have shown that there is a continued need for gender equality in the field of obstetrics and gynecology. 6 As the literature suggests, about half of the women do not care about their gynecologist’s sex, whereas only a small percentage, ranging from 1.2 to 6%, would choose a male gynecologist. 7-10 Fischer demonstrated that 75% of patients surveyed reported no "strong preference concerning the gender of their obstetrician- gynecologist." 9 This same 2002 study showed that 4% of respondents preferred male providers, while 21% had a preference for female providers. In a 2002 survey of postpartum patients , Howell et al., 4 reported similar findings for gender preferences. Overall, 34% of respondents preferred a female obstetrician, 7% a male obstetrician, and 58% expressed no gender preference.However, we must note that a 15-25% of the women consider the sex of the doctor to be an important factor in choosing their gynecologist. 3,10,11 Furthermore, gender could make a significant difference in the type of services offered. For example, one survey of 2525 women in the United States reported that patients of female general practitioners or internists were more likely to receive a Pap smear than were patients of male general practitioners. 6 The matter of the preference of the gynecologist based on sex does not have only an academic interest, but also a practical one for the medical community, since it affects the decision for the doctor’s specialty. The number of men who wish to become gynecologists worldwide, in the last 2 decades is decreasing steadily, especially in the USA, where the percentage decreased from 53.5% in 1990 to 24% in 2005. 11 In Greece however, the number of female gynecologists is still small, with just 455 in a total of 2,547 in 2006. 12 In case of stabilization of the preference of the female population to female gynecologists, those percentages could change. The purpose of this study was to investigate the preferences of Greek women in regard to the sex of their gynecologist, as well as the factors related to that preference. Material and Method Two hundred women participated in this research. The workplaces where the data were collected were a public hospital, the central offices of some banks and some private companies. Initially, the women, as well as their supervisors were informed regarding the purpose of the study and then the questionnaires were handed out to the women who were interested in participating. Moreover, it was made clear that the data were collected confidentially and that no person could be identified from the results of the study. The data were collected from December of 2006 to January of 2007. A closed –type questionnaire, consisted of 29 questionnaires was used. The questionnaires were completed in the presence of the female researchers, to whom the participants could ask explanatory questions. The questionnaire was created T The preference of a Female Greek island population in regard to the gender of their gynecologist 58 pp:57-65 E-ISSN:1791-809X www.hsj.gr Health Science Journal® All Rights Reserved WWW.HSJ.GR – HEALTH SCIENCE JOURNAL ® VOLUME 4, ISSUE 1 (2010) after a review of the foreign literature, based on the questionnaires of other studies dealing with the same or similar subject. It contained questions regarding the demographic data of the subjects, the use of gynecological Health Care Services as well as the choice they make regarding their obstetrician – gynecologist. The questions deal with the choice of the doctor, the sources of information regarding the doctor, the reasons that led to them choosing that particular doctor, as well as the characteristics that the Greek women desire their doctor to possess. 13 Statistics Initially, a descriptive statistical analysis was conducted and contingency tables were formed on the questioned variables. The x 2 test was used on the qualitative variables and the t-test on the quantitative variables. From the total of the examined variables, the ones that presented a significant statistic correlation with the choice of the sex of the gynecologist were identified. The choice of the sex (male- female) was considered as a dual variable and we entered the variables correlated significant statistically with the choice of the sex into a logistic regression model. In that model, it was shown that eventually only a few variables were correlated significant statistically with the choice of the sex of the doctor. The statistic model SPSS, 13.0 for Windows was used in order to draw the conclusions of this research. Results 200 women took part in the study. The average age of the women of the sample was 43±11.02 years old, with 18 years being the minimum and 71 the maximum age. Eighty seven percent (174) of the women were married, with an average age of 42±10.52 years (Table 1). The average age of the single women was 34±12.01 years. A 55.5% had 1-2 children. A 79.5% (159) of the women were working , while 87.1% of the women reported up to 1,500 € as their monthly income. Regarding their educational level, 5% were Elementary graduates, 12.5% were Junior High School graduates, 45% were High School Graduates or Technical School of secondary education graduates, 36% University or Higher Technical Educational Institute graduates, while 3% of the respondents reported they had completed their post-graduate studies (Table 2). Forty –five percent of the women who participated in the research did not have a preference based on the sex of their doctor, whereas 25% of them stated they preferred a man and 30% a woman (Table 3). Regarding the correlation of the sex preference with the family status, the single women preferred a male gynecologist with a significant statistic difference (Table 4). The age of the first visit to the gynecologist was correlated with the choice of the sex of the doctor, since the women who had visited a gynecologist before they reached an average 20 years of age (19.71) preferred a man, with a significant statistic difference in comparison to the women who were 2 years older (21.76) (Table 5). The age group 58-73 years old (born in the period 1951-1960) preferred a female gynecologist, with a significant statistical difference compared to women who were 28-58 years old. The majority of the women of age 18-28 years old also preferred a male gynecologist (Table 6). The women who conducted regular breast exams (every year) stated that they preferred a male gynecologist (25 out of 32 women) in contrast to the women who conducted the exam less regularly, who preferred a female gynecologist (Table 7). We found similar results for the women who conducted regular Pap tests. The women who were conducting an annual check preferred a man in their majority (28 out of 45 women), whereas the ratio changed in favor of the female gynecologist, when the test was conducted less regularly (Table 8). As seen in Table 9, based on the results from the analysis of a logistic regression statistic model, in which we included the variables that initially correlated with the choice of the sex and The preference of a Female Greek island population in regard to the gender of their gynecologist 59 pp:57-65 E-ISSN:1791-809X www.hsj.gr Health Science Journal® All Rights Reserved WWW.HSJ.GR – HEALTH SCIENCE JOURNAL ® VOLUME 4, ISSUE 1 (2010) using as a dependent variable the potential preference of a male gynecologist, the age of the first visit and the breast exam presented, in comparison to the others, the largest statistically significant correlation at a significance level p<0.05 with the sex of the gynecologist. The women who visited a gynecologist in a younger age were, by average, 1.2 times more likely to choose a male gynecologist (CI1.02-1.41). The women who were conducting less regular breast exams were, by average, 1.7 times more likely to choose a female gynecologist (CI1.1- 2.63). Discussion In this research, it was found that about half of the women exhibited a preference based on the sex of their gynecologist, with their majority choosing a female gynecologist. The above finding is in agreement with the results of the international literature, from which we can draw the conclusion that most women prefer female gynecologists. 4-9 However, the percentage of women who do not have a preference based on sex or they do not consider it to be a decisive factor in their final choice is often larger, sometimes even reaching 75%. 9 That fact is often attributed to stereotypes and prejudices that exist in every society regarding the qualities of the sexes, and which in many cases influence the behavior of people in their social relationships. According to the literature, the patients believe that a female gynecologist is more compassionate and largely possesses the so called humanitarian values, whereas there is the conviction that men are more capable on “technical issues” and more rigid . 1,14-16 It has also been found that women devote more time to the patient, they talk more to her and they focus more on her feelings than men. Moreover, they are friendlier to the patient and they encourage her to express herself and be a part of the therapeutic process. 17-21 Since the patients consider women stereotypically to be more humane, it has been found that 83% of women choose a female gynecologist, based on the display of photographs, without any additional information. 11 In the study of Roter et al., 21 and in a sample of 612 women , more than 50% reported that they preferred a female doctor on health issues of gynecological nature 21 These results agree with the findings of the study of Nichols 22 of conducted in a sample of 2,000 women, where 54% of the participants reported that they preferred a female doctor to take their Pap smear, 48% that they preferred a woman for their breast exam and 36% that they preferred a woman to take a sample of vaginal fluid for culture. 22 The same is true even in the case of a student or a resident being present during the gynecological exam, which supports the role of the social factors. The first question deals with the presence of students during a gynecological exam, where 77.34% of the respondents stated that they did not mind the presence of female students, whereas only 51.4% said that they would allow male students to be present during the exam of their genitals, which makes a statistically significant difference. 3 Moreover, in another research conducted on 1,078 women, even though 92% of the respondents would allow a female resident gynecologist to examine them, only 69% would be willing to be examined by a male resident gynecologist. Therefore, there are women who emphasize more on the sex of the doctor, than on his/her level of education. 23 However, the way the patients choose their doctor is not fully understood and it is contradictable in many occasions. Besides, we should point out that, in many cases, the patients eventually pick a male gynecologist, even if they have answered that they would prefer a woman in the related question. As it is concluded by the studies that have dealt with the matter of the choice of the obstetrician-gynecologist, the recommendations by friends and colleagues, the clinic the doctor is working at and his/her academic skills, and also his/her bed manners are more important factors than the sex. Most patients do not have a gender The preference of a Female Greek island population in regard to the gender of their gynecologist 60 pp:57-65 E-ISSN:1791-809X www.hsj.gr Health Science Journal® All Rights Reserved WWW.HSJ.GR – HEALTH SCIENCE JOURNAL ® VOLUME 4, ISSUE 1 (2010) preference and wish their doctor to possess knowledge, skills and experience. 4,24,25 The educational level, the ethnicity, the religious beliefs, the cultural traditions and the socioeconomic status play some role in the choice of the gynecologist. Professionalism and courtesy come ahead as criteria, in relation to the doctor’s academic skills and his/her availability. 1 The findings of this study allow us to conclude that parameters such as the family status, the frequency of conduction of clinical / para-clinical exams, as well as the age of the first trip to the gynecologist are correlated with the choice of the sex. Indeed, studies have attempted to reveal a connection between the demographic information of the respondents and their preference of the sex of their doctor. It seems that the sex of the doctor is more important to younger women who don’t have any children. 3,23 A possible explanation for that phenomenon could be that a woman of older age is ,on one hand, more familiar with the process of the gynecological exam and, on the other hand, considers other qualities of the doctor, such as knowledge and experience, to be more important than his/her sex. It is concluded that the older age, the family status (married) and the birth history are correlated with the long term relationship with the gynecologist. That can be attributed to the different needs of married women, who were satisfied with the prenatal care, and that is why they continue visiting the same obstetrician-gynecologist over the years 1 . It has also been found that single women and women who have had children tend to prefer male gynecologists. 1 The women of the sample, who visited the gynecologist for the first time when they were averagely under 20, seem to prefer a male gynecologist. That can possibly be attributed to the fact that under 20 years of age, the frequency of marriage, as well as procreation is small (in our sample none of the women under 20 was married). It has also been found that women consider men to be more appropriate for handling surgical procedures, whereas c-sections are conducted more frequently by men. 16,26 It is possible that the invasive nature of exams such as the Pap smear or the skills required for examining the breast make women follow some stereotypes in their choice of a male gynecologist. A factor that should be taken under consideration in assessing the results of this study is the small number of Greek female gynecologists, that is significantly smaller than in other countries, which could, to an extent, explain the increased, proportionally, preference of male gynecologists in relation to other countries. Indeed, according to the data from Greek Medical.Association ( GMA), in 2006, there were only 445 women gynecologists, whereas the men were 2,092. 12 Conclusions Τhe women obstetricians- gynecologists come ahead in the preference of women, noting that about half of the women consider sex to be a rather unimportant factor. The younger age during the first visit and the regular breast exam are positively correlated with the choice of a male gynecologist. Other parameters, such as the woman’s age, her family status, and also the frequency she is conducting a Pap test, also play a potential role in the choice of the sex of the gynecologist. Bibliography 1. Piper I, Shvarts S, Lurie S. Women's preferences for their gynaecologist or obstetrician. Patient Educ Couns. 2008 ;72(1):109-14 2. Donahue KE, Ashkin E, Pathman DE. Length of patient-physician relationship and patients' satisfaction and preventive service use in the rural south: a cross- sectional telephone study. BMC Fam Pract. 2005;4(6):40 3. O’ Flynn N, Rymer J. Women’s attitude to the sex of medical students in a gynaecology clinic: cross sectional surney. BMJ. 2002 ;325(7366) :683-684. The preference of a Female Greek island population in regard to the gender of their gynecologist 61 pp:57-65 E-ISSN:1791-809X www.hsj.gr Health Science Journal® All Rights Reserved WWW.HSJ.GR – HEALTH SCIENCE JOURNAL ® VOLUME 4, ISSUE 1 (2010) 4. Howell EA, Gardiner B, Concato J. Do women prefer female obstetricians? Obstet Gynecol. 2002;99(6):1031-5. 5. Cassard SD, Weisman CS, Plichta SB, Johnson TL. Physician gender and women’s preventive services. J Wom Health 1997;6(2):199. 5. Chandler PJ, Chandler C, Dabbs ML. Provider gender preference in obstetrics and gynecology: a military population. Mil Med. 2000;165(12):938-40 6. Schmittdiel J, Selby JV, Grumbach K, Quesenberry CP Jr. Women's provider preferences for basic gynecology care in a large health maintenance organization. J Womens Health Gend Based Med. 1999; 8(6):825-33 7. Webb R, Opdahl M. Breast and pelvic examinations: easing women's discomfort. Can Fam Physician. 1996 ;42:54-8 8. Zuckerman M, Navizedeh N, Feldman J, McCalla S, Minkoff H. Determinants of women's choice of obstetrician/gynecologist. J Womens Health Gend Based Med. 2002;11(4):175- 80 9. Fisher WA, Bryan A, Dervaitis KL, Silcox J, Kohn H. It is not necessarily so: most women do not strongly prefer female obstetrician-gynaecologists. J Obstet Gynaecol Can. 2002;24(9):885-8 10. Kerssens JJ, Bensing JM, Andela MG. Patient preference for genders of health professionals. Soc Sci Med. 1997 ;44(10):1531-40 11. 11. Schnatz PF, Murphy JL, O'Sullivan DM, Sorosky JI. Patient choice: comparing criteria for selecting an obstetrician- gynecologist based on image, gender, and professional attributes. Am J Obstet Gynecol. 2007;197(5):548.e1-7 12. GreekMedicalAssociation files, 2006 13. Davou E, Katostaras T. Greek woman’s preference regarding their gynaecologist’s age. Obstetrics and Gynaecology Issues 2006; 1(1) :44-47. 14. 14. Plunkett BA, Kohli P, Milad MP. The importance of physician gender in the selection of an obstetrician or a gynaecologist. Am J Obstet Gynecol. 2002 ;186(5):926-8. 15. Johnson AM, Schnatz PF, Kelsey AM, Ohannessian CM. Do women prefer care from female or male obstetrician- gynaecologists? A study of patient gender preference. J Am Osteopath Assoc. 2005 ;105(8):369-79. 16. Rizk DE, El-Zubeir MA, Al-Dhaheri AM, Al- Mansouri FR , Al-Jenaibi HS.Determinants of women's choice of their obstetrician and gynaecologist provider in the UAE. Acta Obstet Gynecol Scand. 2005 ;84(1):48-53. 17. Uskul AK, Ahmad F. Physician-patient interaction: a gynaecology clinic in Turkey. Soc Sci Med. 2003;57(2):205-15. 18. Roter DL, Hall JA, Aoki Y. Physician gender effects in medical communication: a meta-analytic review. JAMA. 2002;288(6):756-64. 19. Hall JA, Debra RL. Do patients talk differently to male and female physicians? A meta-analytic review. Patient Educ Couns 2002; 48(3):217-224. 20. Bylund CL, Makoul G. Empathic communication and gender in the physician-patient encounter. Patient Educ Couns. 2002;48(3):207-16. 21. Roter DL, Geller G, Bernhardt BA, Larson SM, Doksum T. Effects of obstetrician gender on communication and patient satisfaction. Obstet Gynecol.1999 ;93(5Pt 1):635-41. 22. Nichols S. Women’ s preference for sex of doctor: a postal surney. J R Col Gen Pract 1987;33(305):540-43. 23. Phillips D, Brooks F. Women patients' preferences for female or male GPs. Fam Pract. 1998;15(6):543-7. 24. Rifkin JI, Shapiro H, Regensteiner JG, Stotler JK, Schmidt B. Why do some women refuse to allow male residents to perform pelvic exams? Acad Med. 2002;77(10):1034-8. 25. Franks P, Bertakis KD. Physician gender, patient gender, and primary care. J Womens Health (Larchmt). 2003;12(1):73-80. The preference of a Female Greek island population in regard to the gender of their gynecologist 62 pp:57-65 E-ISSN:1791-809X www.hsj.gr Health Science Journal® All Rights Reserved WWW.HSJ.GR – HEALTH SCIENCE JOURNAL ® VOLUME 4, ISSUE 1 (2010) 26. Mitler LK, Rizzo JA, Horwitz SM. Physician gender and cesarean sections. J Clin Epidemiol. 2000 ;53(10):1030-5 . Appendix Table 1. Distribution of the sample according to their age Ν % Μean( ± SD), min-max Age (years) 200 100,0 43 ± 11,02 71-18 Age of married people 174 87,0 42± 10,52 Age of unmarried people 26 13,0 34± 12,01 Total 200 100,0 Table 2. Distribution of the sample according to their socio-demographic data Sociodemographic data Ν % Number of children None 55 27,5 One 34 17,0 Two 77 38,5 >3 34 17,0 Total 200 100,0 Employment Yes 159 79,5 No 41 20,5 Total 200 100,0 Monthly income < 500 euros 32 16,5 500-1000 70 36,1 1000-1500 67 34,5 1500-2000 16 8,3 > 2000 9 4,6 Total 194 100,0 Educational level Elementary graduates 10 5,0 Junior high school graduates 25 12,5 High school and technical schools 90 45,0 Universities/TEI 72 36,0 Post-graduate studies 3 1,5 Total 200 100,0 The preference of a Female Greek island population in regard to the gender of their gynecologist 63 pp:57-65 E-ISSN:1791-809X www.hsj.gr Health Science Journal® All Rights Reserved WWW.HSJ.GR – HEALTH SCIENCE JOURNAL ® VOLUME 4, ISSUE 1 (2010) Table 3. Distribution of the sample according to gender Gender Ν % Man 50 25 Woman 60 30 No preference 90 45 Total 200 100 Table 4. Family status and gender preference crosstabulation Family status Gender preference P Man Woman Yes 46 46 Engaged /Married No 4 14 Total 50 60 0.039 x2 Table 5. Age of first visit and gender preference Gender preference N P Age of first visit Men 42 19,71 Women 46 21,76 0.009 Total 88 t- test Table 6. Contingencies between women’s age and gender related preference Gender preference Age group ( birth decade) P 1945- 1950 1951- 1960 1961-1970 1971-1980 1980-today Men 4 4 20 15 7 Women 5 14 16 10 15 Total 9 18 36 25 22 0.005 The preference of a Female Greek island population in regard to the gender of their gynecologist 64 pp:57-65 E-ISSN:1791-809X www.hsj.gr Health Science Journal® All Rights Reserved WWW.HSJ.GR – HEALTH SCIENCE JOURNAL ® VOLUME 4, ISSUE 1 (2010) x2 Table 7. Frequency of mammary examination and gender preference Every year Every two years Less often Never P Gender preference Man 25 5 12 8 Woman 7 14 12 27 Total 32 19 24 24 0.005 x2 Table 8 .Test Pap frequency and gender preference Gender preference P Man Woman Test Pap Every year 28 17 Every two years 11 16 Less often 8 10 Never 3 17 0.005 Total 50 60 x2 Table 9. A statistical model of logistic regression , for gender gynecologist choice probability (man =1, woman=2) Variable Odds ratio 95% CI for Exp(B) R P Lower Upper Married 4.94 0.84 28.86 0.10 0.08 Age of first visit 1.20 1.02 1.41 0.15 0.02 Test pap examination 1.26 0.76 2.09 0.00 0.38 Mammary examination by gynecologist (never=3 regularly=0) 1.70 1.10 2.63 0.17 0.02 Age group 1.02 0.61 1.69 0.00 0.95 Age group 1.02 0.61 1.69 0.00 0.95 The preference of a Female Greek island population in regard to the gender of their gynecologist 65 pp:57-65 E-ISSN:1791-809X www.hsj.gr Health Science Journal® All Rights Reserved . model, in which we included the variables that initially correlated with the choice of the sex and The preference of a Female Greek island population in regard to the gender of their gynecologist. reported that they preferred a female doctor to take their Pap smear, 48% that they preferred a woman for their breast exam and 36% that they preferred a woman to take a sample of vaginal fluid. skills, and also his/her bed manners are more important factors than the sex. Most patients do not have a gender The preference of a Female Greek island population in regard to the gender of their